Basic Information
| Provider Information | |||||||||
| NPI: | 1437802915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIAFAGLEONE | ||||||||
| FirstName: | DOMINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882624 | ||||||||
| FaxNumber: | 2177577550 | ||||||||
| Practice Location | |||||||||
| Address1: | 3225 HEDLEY RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627116248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177267300 | ||||||||
| FaxNumber: | 2177265989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2022 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149.023139 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 149023139 | 01 | IL | LCSW | OTHER |